Myeloma Canada

InfoGuide Series

Understanding Your Blood and Blood Tests

www.myeloma.ca

This InfoGuide is for people living with myeloma, their families and their caregivers. It will help you learn more about the different types of blood cells, the effects Introductionof myeloma and myeloma treatments on the blood, and the key blood tests involved in diagnosing and monitoring myeloma. It also gives you tips on how to track blood test results.

As you read through this InfoGuide, you may refer to the “More detail” boxes to read more about selected topics, “Self-help” boxes if you want tips on how to make your healing journey easier, and “Key point” boxes which highlight important facts or instructions. Terms that might be new to you appear in bold the first time they are used. These terms are described in the Glossary beginning on page 16. There is also space for you to write down questions for and answers from your healthcare team on page 15.

DisclaimerThe information in this InfoGuide is not meant to replace the advice of your medical team. They are the best people to ask if you have questions about your individual situation.

i | Myeloma Canada is a registered non-profit organization created by, and for, people living Myelomawith multiple myeloma. Canada As the only national organization exclusively devoted to the Canadian myeloma community, Myeloma Canada has been making myeloma matter since its founding in 2005. Working with leading myeloma researchers and clinicians as well as other cancer organizations and local support groups across Canada, Myeloma Canada seeks to strengthen the voice of the Canadian myeloma community and improve the quality of life of myeloma patients, their ■ caregivers and families through education, awareness, advocacy and research. ■ ■Myeloma Canada’s goals are to: ■ Provide educational resources to patients, families and caregivers Increase awareness of the disease and its effects on the lives of patients and families Advance clinical research and promote access to new drug trials in Canada Facilitate access to new therapies, treatment options and healthcare resources This InfoGuide is dedicated to the patients and their families who are living with myeloma and to the healthcare professionals and researchers who are working towards more effective treatments and a cure. If you would like a more general overview of what myeloma is, how it is diagnosed, the most common treatments for it and many of the challenges you face in living with this disease, we recommend you read Myeloma Canada’s Multiple Myeloma Patient Handbook. You can order the Handbook free of charge by emailing Myeloma Canada at [email protected] or by calling toll-free at 1-888-798-5771. The Multiple Myeloma Patient Handbook and other InfoGuides are also available for download at www.myeloma.ca.

ii | The Micro-Universe of Your Blood Table of Contents1 Multiple Myeloma and Your Blood 5 Multiple Myeloma Treatments and Your Blood 7 Blood Tests for Multiple Myeloma 9 Questions for Your Healthcare Team 15 Glossary 16 Make Myeloma Matter 21 Acknowledgements 22 Resources 23

iii | On the surface, blood seems fairly simple. It, however, plays an essential role in your health andThe is actually Micro-Universe quite complex once you look of at itYour under a microscope.Blood It helps to energize you by transporting nutrients and oxygen throughout your body and it redistributes body heat to keep you feeling comfortable. Learning more about blood and its components will help you better understand how myeloma and its different treatments affect your blood and explain the purpose of the blood tests that you will undergo as your disease is diagnosed and monitored.

Plasma Red blood cell

Red blood cells Plasma White blood cells Platelets45% 55% White blood cell

Figure 1 – Composition of the blood. Nearly 55% of blood is made up of Platelet a fluid part called plasma, while the remaining 45% is solid, consisting of red blood cells, white blood cells and platelets.

The Micro-Universe of Your Blood 1 | Red blood blood cells cells (RBC's) – theor erythrocytes oxygen carrierscarry oxygen to your tissues to keep you healthy and give you energy. They also transport carbon dioxide back to your lungs so it can leave your body when you exhale. Erythrocytes get their red colour from a protein they carry called hemoglobin (Hgb or Hg). If you don’t have enough red blood cells (a condition called anemia), the other cells in your body won’t receive enough oxygen to function properly and you will feel weak and tired. Reticulocytes are young, immature RBC’s that eventually turn into mature RBC’s.

Figure 2 – Red blood cells (RBC's) transport oxygen to the tissues and carbon dioxide to the lungs.

The Micro-Universe of Your Blood 2 | White blood blood cells cells(WBC's) – orkeeping leukocytes you are safepart of your body’s defense system. Although your body has many other levels of defense – most of which are designed to keep disease- causing organisms from entering your blood stream – they can fail. That’s when your leukocytes kick into action to fight infections and diseases that have reached or originated in your blood. If you have too few white blood cells (a condition called leukopenia) you will be more likely to get sick with colds, flu and other infections.

Figure 3 – White blood cells (WBC's) help to fight infections and disease.

More detail

The many types of white blood cells There are five different kinds of white blood cells, or leukocytes: 1. Neutrophils kill and ingest bacteria and fungi, and clear away what they identify as “foreign” debris 2. Lymphocytes are divided into two types. B-lymphocytes can develop into plasma cells, the cells that produce different types of antibodies called immunoglobulins that protect us from disease. T-lymphocytes and natural killer cells protect against viral infections, and can detect and destroy some types of cancer cells 3. Monocytes eat up dead or damaged cells and help defend against infections 4. Eosinophils kill parasites and are involved in allergic reactions 5. Basophils are involved in inflammatory and allergic reactions

The Micro-Universe of Your Blood 3 | PlateletsIf you get injured, – damage platelets, orcontrol thrombocytes, help stop bleeding and repair damage to your ■blood vessels by helping to form blood clots. If you have too few platelets (a condition called thrombocytopenia), you could experience one or more of the following signs or symptoms: ■

■ Easy or excessive bruising Prolonged bleeding from cuts Spontaneous bleeding from your gums or nose

β Blood proteins, proteins or serum – protection proteins, are proteins in your found plasma in your blood plasma, the liquid part of your blood. There are several different types of plasma proteins, but the most important ones for people with myeloma to know about are immunoglobulins, albumin and beta-2 ( 2) microglobulin. κ λ Immunoglobulins are antibodies that protect us against disease. Each immunoglobulin has two parts: two heavy chains that are type G, A, D, E or M; and two light chains that are type kappa ( ) or lambda ( ).

Virus or bacteria

Figure 4 – Immunoglobulins (antibodies) are Y-shaped molecules. The heavy and light chains of the antibody contain specific binding sites that attach to bacteria or viruses, ultimately leading to their destruction thereby protecting against disease.

Heavy chain

Light chain

Serum albuminβ is produced in the liver and normally makes up about 60% of human plasma protein.

Beta-2 ( 2) microglobulin is a small protein normally found on the surface of many cells, including lymphocytes, and in small amounts in the blood and urine.

The Micro-Universe of Your Blood 4 | Multiple Myeloma and Your Blood Over-productionNow that you know a bit ofmore plasma about blood, cells it’s – easier too tomuch understand of a how good multiple thing myeloma affects it. This cancer causes a specific type of white blood cell, called a plasma cell, to over- produce. It sounds harmless, especially because plasma cells normally protect us from disease and infection by creating antibodies.

But too many plasma cells can cause a number of problems in your body. If you have myeloma, your plasma cells may make up 10% or more of your bone marrow (the spongy inner core of your bone) instead of the normal 2% to 3%, causing the crowding out and suppression of the production of other types of blood cells that you need, such as red blood cells (see page 2), other types of white blood cells (see page 3) or platelets (see page 4).

More detail

Myeloma: cancer of the bone marrow Because plasma cells are formed from B cells in your bone marrow, multiple myeloma is often referred to as a cancer of the bone marrow.

The malignant or mutated plasma cells also usually pump out only one type of plasma protein (see page 4), called a clone, instead of the variety of immunoglobulins or antibodies that they are supposed to. This abnormal clone is referred to by the medical community as a myeloma paraprotein or monoclonal protein (M-protein), and shows up in blood tests as a monoclonal spike, which is also called an M-spike or M-peak. Your blood tests may additionally show an increase in beta-2 microglobulin.

Multiple Myeloma and Your Blood 5 | Effects of too many plasma cells – decodingMany of the multiple the symptoms myeloma symptoms of multiple you may experience myeloma can be explained by the effects of the cancerous myeloma plasma cells on your blood and bones. Fatigue Myeloma may interfere with your body’s production of red blood cells and can lead to anemia, causing you to look pale, and feel weak, fatigued and short of breath. Repeated infections and fevers, or wounds that are slow to heal Low levels of white blood cells, called leukopenia, can lead your immune system to malfunction, leaving you vulnerable to infections or fevers.

In addition, even though the level of immunoglobulins (antibodies) may be high, a large percentage may be composed of paraprotein, an abnormal antibody that is not effective in fighting infections. Normally, immunoglobulins retain the memory of fighting an infection such as a cold, but in myeloma the malfunction causes the immune system to "forget" how to fight the virus, causing repeated infections. Abnormal bleeding Myeloma and some of the medications used to treat it can interfere with the production of platelets, preventing your blood from clotting normally. A low platelet count, called thrombocytopenia, can put you at risk of bleeding too much if you get hurt.

High level of calcium in the blood (hypercalcemia) The myeloma cells in your bone marrow may damage your bone, creating weak spots (called lytic lesions), or inhibiting the normal rebuilding of bone, leading to a thinning of bone and conditions such as osteopenia and osteoporosis.

When bone breaks down, the calcium it contains is released into the bloodstream. Too much calcium in your blood can cause loss of appetite, nausea, vomiting, frequent urination, increased thirst, constipation, weakness, confusion or, in extreme cases, stupour or coma.

This bone degeneration might also cause bone pain, particularly in your back or ribs, or fractures. For more information, consult the Myeloma Canada InfoGuide, Myeloma Bone Disease. Kidney (renal) damage Too much protein and calcium in the blood can damage your kidneys, increasing your risk of developing kidney, or renal, disease. Light chain myeloma can also increase the risk of kidney damage.

Hyperviscosity syndrome In some cases, the overabundance of proteins in your blood can cause your blood to thicken – this is called hyperviscosity syndrome. Symptoms of hyperviscosity syndrome can include bleeding from the nose or mouth, blurred vision, neurologic symptoms (e.g., headache, dizziness and confusion), visual disturbances and heart problems. Multiple Myeloma and Your Blood 6 | The medications that are prescribed to treat myeloma can also affect your blood. The chart below summarizes how some of the more common myeloma medications can affect your blood, but keep inMultiple mind that it is very Myeloma unlikely that you willTreatments experience all of these and potential Your side effects.* Blood Too few red red few Too blood cells: higher risk of anemia white few Too blood cells: higher risk of infections few Too higher platelets: risk of bleeding much too Higher risk of deep vein (DVT)thrombosis inor blood clots the legs Higher blood glucose (sugar) levels

Medication ✓ ✓ ✓

® Bortezomib ✓ ✓ ✓ (Velcade )

® Cyclophosphamide ✓ ✓ (Cytoxan )

® Dexamethasone ✓ ✓ ✓ ✓ (Decadron )

® ® Doxorubicin ✓ ✓ ✓ ✓ (Adriamycin , Doxil )

® Lenalidomide ✓ ✓ ✓ (Revlimid ) ® ✓ ✓ ✓ ✓ Melphalan (Alkeran )

® Pomalidomide ✓ ✓ (Pomalyst ) ✓ ✓ ✓ Prednisone Thalidomide®

* Please(Thalomid note that these) listed side effects are blood-related only. Other side effects can also occur with these medications. Please check with your doctor or pharmacist for a complete list.

Multiple Myeloma Treatment and your Blood 7 | Self-help Help yourself to safer treatment Whenever you are prescribed a new medication, be sure to talk with your healthcare team, including your pharmacist, to make sure you understand how ■to take it and what its potential side effects might be. Here is a list of questions to ask: ■ How do I take this medication?

■ Can this medication interact with food, vitamins, supplements or other drugs I’m taking? ■ What are all of the potential side effects? ■ Which side effects are serious and need to be treated immediately?

Are there ways to treat or manage the less serious side effects (e.g., by changing the medication or dose, or using supportive therapies that help reduce the side effect)?

Multiple Myeloma Treatment and your Blood 8 | There are many different ways to diagnose and track multiple myeloma, but you can find out a lot from a few simple blood tests. The state of your blood can reveal whether or not you have this disease,Blood how farTests it has progressed for andMultiple whether your treatments Myeloma are keeping it under control.

DiagnosticThe complete blood blood count tests – your –basic finding starting pointout if you have myeloma The most basic blood test your doctor will do is called a complete blood count (CBC). A CBC measures the total or "absolute values" of red blood cells, white blood cells and platelets. This test can help your doctor identify the cause of symptoms such as weakness, fatigue or bruising, and can help in the diagnosis of many other conditions, such as anemia and infection. Although everyone has different amounts of blood cells in their body, there is a “normal range” for each type of cell to do its job and keep you well. This range will vary depending on your gender, age and the lab conducting the test. Additional detail is provided by the blood differential test that measures the percentage of each type of white blood cell (neutrophils, lymphocytes, monocytes, eosinophils and basophils) that you have in your blood. ■ If you have myeloma, your doctor will be most interested in the following components of your blood: ■ Red blood cells: shows whether there are enough red blood cells to properly transport oxygen to your tissues ■ White blood cells: shows whether there are enough white blood cells for your immune system ■ to protect you against diseases and infections Platelets: indicates whether there are enough platelets for your blood to clot properly ■ Albumin: shows whether your liver is functioning properly, and if not, how serious the problem ■ is; albumin levels are used in the International Staging System (see page 11) Creatinine: reveals your kidney function ■ Glucose: measures the amount of glucose, or sugar, in your blood, which can be high if you’re taking certain medications (e.g., steroids such as dexamethasone or prednisone), or if you have diabetes or pre-diabetes Calcium: too much in your blood can be a sign of bone breakdown Blood Tests for Multiple Myeloma 9 | Key point It’s important to get your blood tested regularly because it can be affected by both your myeloma and your myeloma treatments.

Specialized myeloma blood tests – a more targeted approach ■ There are several blood tests that can give you and your doctor a lot more information than a CBC: Serum protein electrophoresis (SPEP): can show whether there is an unusual amount of one immunoglobulin (i.e., antibody) in the blood. If you have multiple myeloma, you will probably have a higher than normal level of a certain immunoglobulin, which shows up on a blood test as a monoclonal protein, also called an M-protein, paraprotein, M-spike or M-peak. For IgA myeloma, the M-protein component is often low, so occasionally the total IgA immunoglobulin level is monitoredSerum Protein instead Electrophoresis of the actual M-protein.

Figure 5 – Serum protein electrophoresis (SPEP). Comparison between a normal test result and one in Normal multiple myeloma. The latter Multiple myeloma shows an M-spike i.e. a higher than normal level of one type of immunoglobulin or antibody. αα β γ

1 2 ■ Albumin

■ Immunofixation (IFE): can reveal whether or not you have a monoclonal protein, as well as the type of myeloma protein ■ κ Quantitative immunoglobulin test: measures the total amount (both normal and λ abnormal) of three different kinds of antibodies: immunoglobulin (Ig) G, A and M ■ β A serum free light chain assay (sFLC) can measure the amount of kappa ( ) and lambda ( ) light chains in the blood

■ Beta-2 ( 2) microglobulin: the blood should be tested at the time of diagnosis to determine the level of beta-2 microglobulin, a small immunoglobulin found on the surface of many cells. The beta-2 microglobulin level is used in the International Staging System (see page 12) Blood urea nitrogen (BUN): a test used along with the creatinine test to evaluate kidney function Blood Tests for Multiple Myeloma 10 | More detail κ λ Common and rare types of myelomaκ λ κ λ κ λ About 65% of myeloma patients have IgG type myeloma, with either or light chain proteins (written as IgG or IgG ). The next most common type of myeloma is IgA, with either or light chains (written as IgA or IgA ). IgM, IgD and IgE myelomas are quite rare. In about 10% of cases, the myeloma cells produce only light chains and no heavy chains; this is referred to as “light chain” or “Bence Jones” myeloma. In rare cases (about 1% to 2%), the myeloma is non-secretory, which means there is very little or no monoclonal protein of any type. This type of myeloma can’t be measured with a simple blood test.

StagingIf your myeloma blood is active tests or symptomatic – understanding – meaning that your you diseasehave changes path in your blood and symptoms such as bone pain or fatigue – your doctor can conduct blood tests to figure out the level, or stage, of your disease. Knowing what stage your disease is at can help your healthcare team determine what kind of treatment is best for you.

There are currently two systems for diagnosing and staging symptomatic myeloma, each of which has different ways of defining the three myeloma stages.

1. The Durie-Salmon Staging System is good for assessing how extensive your disease is. It uses four blood tests: hemoglobin count, calcium level, monoclonal or paraprotein level (i.e., M-spike) and creatinine level.

2. The International Staging System (ISS) is based on two blood tests: beta-2 microglobulin count and albumin level. The ISS is also used as a prognostic tool.

Blood Tests for Multiple Myeloma 11 | Stage ISS µ Durie-Salmon ≥ I ß2 microglobulin All of the following must be present: is less than 3.5 g/mL a. Hemoglobin 100 g/L AND Albumin is equal to or b. Normal serum calcium (< 2.88 mmol/L) c. Low levels of monoclonal protein: greater than 35 g/L • 0 IgG < 5 g/L • 0 IgA < 3 g/L • Urine light chain < 4 g per 24 hrs d. Bone X-ray, normal bone structure (scale 0), µ or solitary bone plasmacytoma only

II ß2 microglobulin Fitting neither Stage I nor Stage III is less than 3.5 g/mL, but albumin is less than 35 g/L OR µ ß2 microglobulin is between 3.5 and 5.5 g/mL, irrespective of albumin µ III ß2 microglobulin One or more of the following must be present: is equal to or greater a. Hemoglobin < 85 g/L than 5.5 g/mL b. Elevated serum calcium ( > 2.88 mmol/L ) c. High M-protein production rates • 0 IgG > 7 g/L • 0 IgA > 5 g/L • Urine light chain > 12 g per 24 hrs d. Advanced lytic bone lesions on skeletal survey µ Subclassification: a. Relatively normal renal functionµ (serum creatinine less than 180 mol/mL ) b. Abnormal renal function (serum creatinine equal to or greater than 180 mol/mL )

Blood Tests for Multiple Myeloma 12 | Self-help Help yourself to easier test tracking Although it’s not necessary, it is recommended to track your blood test results so you can monitor the changes in your blood over time. Blood test tracking may also help you identify questions to ask your healthcare team (see page 15). You can use the tracking chart below, create your own log in a blank notebook or graph your test results using a spreadsheet.

Normal range Date and Result Name of blood test (Canadian values)* Total protein 60–80 g/L Total immunoglobulin IgG...... 5.65–17.65 g/L IgA ...... 0.85–3.85 g/L IgM ...... 0.55–3.75 g/L  Total M protein 0.0 g/L (M-spike) ß2 microglobulin 0.0–3.0 g/mL

Albumin 35–50 g/L Hemoglobin Women: (Hgb or Hb) 120–160 g/L Men: 140–180 g/L 12 Total erythrocytes Women: or red blood count 4.2–5.4 x 10 /L 12 (RBC) Men: 4.6–6.2 x 10 9/L Total white blood cell 3.5–12.0 x 10 /L count (WBC) 9 Neutrophils 1.7–7.0 x 10 /L9 Platelet count 150–400 x 10 /L Other: Other:

* PleaseOther: note that normal values may vary from one lab to another. The ranges are for reference only.

Blood Tests for Multiple Myeloma 13 | Date and Result

Blood Tests for Multiple Myeloma 14 | When it comes to your health, you can never ask too many questions! Your healthcare team is thereQuestions to support you, andfor make Your sure you Healthcareunderstand what’s happening Team to your body and why. In the space below, you can write down any questions you have for your doctors or nurses, and ■take this InfoGuide with you to medical appointments so you can refer to it. Here are some questions to start you off: ■ What blood tests have I had? What were the results? ■ What type of myeloma do I have? ■ What stage is it at? ■ What other tests will I need?

What medications will I need to take? How could they affect my blood?

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Questions for Your Healthcare Team 15 | Albumin: A protein made by the liver that is tracked by blood tests as a wayGlossary to monitor liver function. Albumin may also be used along with creatinine and blood urea nitrogen (BUN) to track kidney function. In addition, the albumin level is used in the International Staging System.

Anemia: Low red blood cell count, causing fatigue and weakness.

Basophil: A white blood cell, or leukocyte that eats up dead or damaged cells and helps to defend the body against infection. β Bence-Jones myeloma: See lightβ chain myeloma.

Beta-2 ( 2) microglobulin: A very small immunoglobulin (microglobulin) found on the outside of cells; a test for 2 microglobulin levels in the blood is done at diagnosis and is used in the International Staging System.

Blood urea nitrogen (BUN): A test used along with the creatinine test to evaluate kidney function.

Calcium: A mineral that is an important part of bones and teeth. When bone is broken down by the body, calcium is released into the blood stream.

Clone: An exact copy. Multiple myeloma is a cancerous proliferation of a single clone of plasma cells producing a monoclonal immunoglobulin.

Complete blood count (CBC): A common set of tests that measures the total or "absolute values" of red blood cells, white blood cells and platelets.

Glossary 16 | Creatinine: A byproduct of muscle breakdown, which is transported through the blood to the kidneys to leave the body in the urine. If the kidneys are not functioning well, the creatinine level in the blood will rise.

Erythrocyte: A red blood cell. In a complete blood count (CBC), the red blood count (RBC) measures the number of red blood cells in the blood.

Deep vein thrombosis (DVT): Blood clots in the veins, such as in the legs, which interfere with blood circulation.

Durie-Salmon Staging System: A system for assessing the extent or stage of myeloma. It uses four blood tests: hemoglobin count, calcium level, monoclonal or paraprotein level (also called the M-spike), and creatinine level.

Eosinophil: A lymphocyte that kills parasites and is involved in allergic responses.

Gamma globulin: An immunoglobulin or antibody (see immunoglobulin).

Glucose: A sugar. A high level of glucose in the blood can be a sign of diabetes or pre-diabetes, or it can be a side effect of high-dose steroid treatment (e.g., with dexamethasone or prednisone).

Heavy chain: One of the main components of immunoglobulins. Immunoglobulins (Ig) are composed of two heavy and two light chains, and there are five types of heavy chains: G, A, D, E and M. Heavy chain myelomas are classified based on the type of heavy chain affected; the most common forms are IgG and IgA.

Hemoglobin: A protein found in red blood cells that can pick up and release oxygen and carbon dioxide. It gives red blood cells their characteristic red colour. In a complete blood count (CBC), the hemoglobin (Hgb or Hb) test measures the amount of hemoglobin in the blood.

Hypercalcemia: A high or excessive level of calcium in the blood. Hypercalcemia may cause constipation, increased frequency of urination, weakness and, in extreme cases, confusion, stupour or coma.

Hyperviscosity syndrome: Abnormal thickening of the blood, usually from an increase in the number of immunoglobulins. Symptoms can include bleeding from the nose or mouth, blurred vision, neurologic symptoms (e.g., headache, dizziness and confusion), visual disturbances and heart problems.

Glossary 17 | Immunofixation (IFE): A test to measure monoclonal proteins (i.e., M-spike or M-peak) that can be performed on a sample of blood or urine.

Immunoglobulin: An antibody or gamma globulin; a form of protein composed of two heavy and two light chains. Immunoglobulins protect against disease and infection.

International Staging System (ISS): A system used to stage and predict myeloma survival. It is based on two blood values: beta-2 microglobulin count and albumin level.

Leukocyte: A white blood cell.

Leukopenia: A low level of leukocytes (white blood cells) in the blood. Leukopenia prevents your immune system from protecting you against infection and disease. κ λ Light chain: One of the main components of immunoglobulins. Immunoglobulins are composed of two heavy and two light chains. Light chains come in two types: kappa ( ) or lambda ( ).

Light chain myeloma: A form of myeloma in which the myeloma cells produce only light chains and no heavy chains; it is also referred to as Bence-Jones myeloma.

Lymphocyte: A type of white blood cell. T-lymphocytes and natural killer cells protect against viral infections, and can detect and destroy some forms of cancer cells. B lymphocytes can develop into plasma cells.

Lytic lesions: Weak spots, holes or “punched out” areas in the bone.

M-peak: Another term for M-spike, an abnormally high level of one type of monoclonal protein.

M-spike: Another term for M-peak.

Microglobulin: A very small immunoglobulin or antibody.

Monoclonal protein: The particular immunoglobulin that cancerous myeloma cells are over-producing.

Monocyte: A type of leukocyte (white blood cell) that clears away dead or damaged cells in the blood and helps to defend against infections.

Neutrophil: A form of leukocyte (white blood cell) that kills and ingests bacteria and fungi, and clears away what it identifies as “foreign” debris.

Glossary 18 | Non-secretory myeloma: An uncommon form of myeloma in which there is little or no monoclonal protein in the blood or urine.

Osteopenia: A condition in which the density of the minerals in the bone is lower than normal, but is not low enough to be classified as osteoporosis.

Osteoporosis: Weakening or thinning of the bone because of abnormally low bone mineral density. Osteoporosis increases the risk of bone breakage (fracture).

Paraprotein: Another term for monoclonal protein, M-protein or M-spike.

Plasma: The yellow fluid that makes up about half of the total blood volume.

Plasma cells: Cells that develop from B lymphocytes, which manufacture different types of immunoglobulins (antibodies).

Plasma proteins: Proteins that circulate in the blood plasma. Some of the most common plasma proteins are albumin, immunoglobulins (antibodies or gamma globulins), microglobulins (small-sized immunoglobulins) and proteins involved in blood clotting.

Platelet: A very small, cell-like particle in the blood that plays a critical role in forming blood clots and stopping bleeding. It is also referred to as a thrombocyte.

Quantitative immunoglobulin test: A blood test that can measure how much of the immunoglobulins IgG, IgA and IgM are in the blood.

Red blood cell (RBC): A type of cell that transports oxygen to the cells of the body and carries carbon dioxide away from the tissue so it can leave the body through the lungs. Red blood cells make up about 40 - 45% of the blood and are produced in the bone marrow. Since they only live for 120 days, continuous production is needed to maintain health.

Renal: Referring to the kidneys.

Reticulocyte: An immature red blood cell typically composing about 1% of the red cells in the human body. Reticulocytes develop and mature in the bone marrow and then circulate for about a day in the blood stream before developing into mature red blood cells.

Serum: The portion of the blood consisting of plasma plus certain plasma proteins. When used in the name of a test (e.g., “serum calcium”) it refers to the level of that component present in the blood.

Glossary 19 | κ λ

Serum free light chain assay (sFLC): A test that measures the amount of kappa ( ) or lambda ( ) light chains in the blood. An assay can be performed on a sample of blood or urine.

Serum protein electrophoresis (SPEP): A blood test to measure the amount of monoclonal protein in the blood.

Thrombocyte: A platelet or small blood cell that is important for helping the blood to clot.

Thrombocytopenia: Low platelet count, which increases the risk of abnormal bleeding and bruising.

White blood cells: Specialized cells that help the body to fight disease and infection. There are five main types of white blood cells: neutrophils, lymphocytes, monocytes, eosinophils and basophils. White blood cells are also referred to as leukocytes.

White blood count (WBC): In a complete blood count (CBC), this measures the total number of white blood cells in the blood.

Glossary 20 | MakeEvery year, MyelomaMyeloma Canada providesMatter information to thousands of people with myeloma and their families and caregivers, and helps many more by providing programs and services such as the annual Myeloma Canada National Conference, Patient and Family InfoSessions, the Myeloma Matters newsletter and webinars.

That is why we need your help. We depend on support and generous donations from people like you to provide support to myeloma patients, their families and their caregivers. All donations are greatly appreciated and allow us to continue our vital work.

WaysDonate You Can Help You can make your donation online at www.myeloma.ca, over the phone by calling toll-free at 1-888-798-5771, or by mailing a cheque payable to Myeloma Canada to: Myeloma Canada 1255 Trans-Canada Highway, Suite 160 Dorval, QC H9P 2V4

Fundraise There are other ways you can support Myeloma Canada, such as taking part in the annual Multiple Myeloma March held in cities across Canada, or by fundraising for Myeloma Canada in your local community. When so much about myeloma is beyond the control of the people that it affects and those who care for them, fundraising can be a rewarding and fun way of doing something positive for yourself and for others affected by myeloma.

Contact the fundraising team toll-free at 1-888-798-5771 for more information, or visit www.myeloma.ca.

Make Myeloma Matter 21 | Myeloma Canada wishes to acknowledge and thank Dr Joanne Hickey of the Health Science Centre in St John’s, NL and Cindy Manchulenko of the Leukemia/BMT Program in Vancouver, BC for their support and guidance in the development of this InfoGuide.Acknowledgements We also wish to thank the many patients and caregivers who provided their valuable input.

Myeloma Canada Scientific Advisory Board Nizar J Bahlis, MD Linda Pilarski, PhD Michael Sebag, MD, PhD Suzanne Trudel, MD Tom Baker Cancer Center Division of Experimental Assistant Professor Assistant Professor Assistant Professor Oncology McGill University Faculty Clinician/Research Scientist University of Calgary Department of Oncology of Medicine Department of Medical Foothills Medical Center Cross Cancer Institute McGill University Health Oncology and Hematology Calgary, AB University of Alberta Centre Princess Margaret Hospital Edmonton, AB Montreal, QC University Health Network Andrew R Belch, MD Member, IMF Scientific Toronto, ON Chaim Shustik, MD Division of Medical Advisory Board Oncology Associate Professor of Darrell White, MD Department of Oncology Donna E Reece, MD Medicine & Oncology Nova Scotia Cancer Centre Cross Cancer Institute Professor of Medicine McGill University Faculty Queen Elizabeth II Health University of Alberta Director, Program for of Medicine Services Centre Edmonton, AB Multiple Myeloma and Royal Victoria Hospital Dalhousie University Related Diseases Montreal, QC Halifax, NS Christine Chen, MD Department of Medical Member, IMF Scientific Assistant Professor Oncology and Hematology Advisory Board Department of Medical Princess Margaret Hospital Kevin J Song, MD Oncology and Hematology University Health Network BC Cancer Research Centre Princess Margaret Hospital Toronto, ON Vancouver General Hospital University Health Network Member, IMF Scientific Vancouver, BC Toronto, ON Advisory Board Rodger Tiedemann, PhD, Richard LeBlanc, MD Tony Reiman, MD ChB, MB Maisonneuve-Rosemont Medical Oncologist Scientist, Ontario Hospital Saint John Regional The mission of the Myeloma Cancer Institute Clinical Assistant Professor Hospital Canada Research Network is Staff Hematologist of Medicine Assistant Dean of Research to conduct clinical and Division of Medical University of Montreal Dalhousie Medicine translational research in a Oncology & Hematology Montreal, QC New Brunswick collaborative manner to improve Princess Margaret Hospital Saint John, NB patient outcomes in multiple Assistant Professor myeloma, and to provide Jean Roy, MD of Medicine scientifically valid and Maisonneuve-Rosemont University of Toronto peer-reviewed consensus Hospital Toronto, ON opinions on the diagnosis and University of Montreal treatment of multiple myeloma. Montreal, QC Acknowledgements 22 | Resources Myeloma( www.myeloma.ca Canada ) Let’s begin with a resource that is unique to Canada, and therefore most pertinent to Canadians.■ On the internet, your first stop should be Myeloma Canada. This bilingual website gives■ you: ■ Information about myeloma and living with myeloma Publications you can download ■ Links to listings of clinical trials currently underway in Canada, as well as the U.S. ■ and elsewhere Events and meetings ■ Information on support groups in communities across Canada, so you can meet with others facing the same challenges and experiences Links to other Canadian and international resources

Joining an existing support group is an excellent way of learning more about myeloma. When you meet with other myeloma patients, you not only benefit from their support and experiences – but you help others. If there is no support group in your area, contact Myeloma Canada for information on how to start one.

Resources 23 | International( www.myeloma.org )Myeloma Foundation The International Myeloma Foundation is a U.S.-based organization that provides information for patients and healthcare professionals and funds myeloma research. Its website will give you access to a wealth of information, including a world-wide listing of support groups. When using this site remember that units of measurement and some drug names may vary from those used in Canada.

Myeloma( www.myeloma.org.uk UK ) Established in 1997, Myeloma UK is the only organization in the United Kingdom dealing exclusively with myeloma.

Resources 24 | ______This InfoGuide was partially funded by unrestricted educational grants from Amgen, Celgene, Janssen and Takeda. Myeloma Canada Mailing Address:

Myeloma Canada 1255 Trans-Canada Highway Suite 160 Dorval, QC H9P 2V4

Telephone:

Toll-free: 1-888-798-5771

E-mail: [email protected]

Website: www.myeloma.ca

Myeloma Canada publications are extensively reviewed by patients and healthcare professionals prior to publication.

Sincere thanks to the fundraising efforts of the Canadian myeloma community who make myeloma matter by helping to advance Myeloma Canada’s objectives of education, awareness, access and research.

Charitable registration number: 862533296RR0001

© 2012 Multiple Myeloma Canada First Edition: September 2012 Revised: February 2016